Fillable Form Ss-6074 - Extension Request - Department Of State printable pdf download

Form Ss-6074 - Extension Request - Department Of State

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State of Tennessee

EXTENSION REQUEST

Department of State

Division of Charitable Solicitations & Gaming

William R. Snodgrass Tennessee Tower

312 Rosa L. Parks Avenue , 8th Floor

Nashville, TN 37243

(615) 741-2555 / (615) 253-5173 - fax

INSTRUCTIONS: Pursuant to T.C.A. § 48-101-506(e), for good cause shown, the secretary may extend the time

for filing a renewal application for a period not to exceed ninety (90) days during which time the previous registration

remains in effect. Please complete the form stating the reason for the extension request.

You will not receive correspon-

dence from the division if the request for extension is granted. You will receive a letter from the division if the request

for extension is DENIED.

Name of Organization:

CO ID:

Contact Name:

FEIN:

Address:

City:

State:

Zip Code:

Telephone Number: (

)

Fax Number: (

)

E-mail:

Reason for extension:

Supporting documentation attached (e.g. IRS Form 8868 - exempt organization extension to file).

SIGNATURE

I certify that the information furnished in this Request of Extension (and all continuation sheets is true and

correct to the best of my knowledge.

Signature of Principal Officer or Authorized Representative:

Print First:

MI:

Last:

Title:

Date:

SS-6074 (Rev. 05/10)

RDA 1742

Form Ss-6074 - Extension Request - Department Of State

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